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Improved survival of children and adolescents with classical Hodgkin lymphoma treated on a harmonised protocol in South Africa. Pediatr Blood Cancer 2024; 71:e30712. [PMID: 37814417 DOI: 10.1002/pbc.30712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/11/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Historic South African 5-year overall survival (OS) rates for Hodgkin lymphoma (HL) from 2000 to 2010 were 46% and 84% for human immunodeficiency virus (HIV)-positive and HIV-negative children, respectively. We investigated whether a harmonised treatment protocol using risk stratification and response-adapted therapy could increase the OS of childhood and adolescent HL. METHODS Seventeen units prospectively enrolled patients less than 18 years, newly diagnosed with classical HL onto a risk-stratified, response-adapted treatment protocol from July 2016 to December 2022. Low- and intermediate-risk patients received four and six courses of adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD), respectively. High-risk patients received two courses of ABVD, followed by four courses of cyclophosphamide, vincristine, prednisone, and dacarbazine (COPDac). Those with a slow early response and bulky disease received consolidation radiotherapy. HIV-positive patients could receive granulocyte colony-stimulating factor and less intensive therapy if stratified as high risk, at the treating clinician's discretion. Kaplan-Meier survival analysis was performed to determine 2-year OS and Cox regression to elucidate prognostic factors. RESULTS The cohort comprised 132 patients (19 HIV-positive, 113 HIV-negative), median age of 9.7 years, with a median follow-up of 2.2 years. Risk grouping comprised nine (7%) low risk, 36 (27%) intermediate risk and 87 (66%) high risk, with 71 (54%) rapid early responders and 45 (34%) slow early responders, and 16 (12%) undocumented. Two-year OS was 100% for low-risk, 93% for intermediate-risk, and 91% for high-risk patients. OS for HIV-negative (93%) and HIV-positive (89%) patients were similar (p = .53). Absolute lymphocyte count greater than 0.6 × 109 predicted survival (94% vs. 83%, p = .02). CONCLUSION In the first South African harmonised HL treatment protocol, risk stratification correlated with prognosis. Two-year OS of HIV-positive and HIV-negative patients improved since 2010, partially ascribed to standardised treatment and increased supportive care. This improved survival strengthens the harmonisation movement and gives hope that South Africa will achieve the WHO Global Initiative for Childhood Cancer goals.
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An exploration of early sleep development in preschool children with and without a familial history of ADHD. Sleep Med 2022. [DOI: 10.1016/j.sleep.2022.05.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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1048 In Vitro Evaluation of the Response of Human Tendon-Derived Stromal Cells to a Novel Electrospun Suture. Br J Surg 2022. [DOI: 10.1093/bjs/znac269.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abstract
Aim
Recurrent tears after surgical tendon repair remain common, with 40% of rotator cuff repairs failing within one year. Repair failures can be partly attributed to the use of sutures not designed for the tendon cellular niche. Synthetic electrospun materials can mechanically support the tendon while providing topographical cues that modulate the immune response to promote wound healing. Here, a novel electrospun suture made from twisted polydioxanone (PDO) polymer filaments is compared to PDS II, a PDO suture clinically utilised in tendon repair.
Method
We evaluated the ability of electrospun suture and PDS II to support the attachment and proliferation of human tendon-derived stromal cells using PrestoBlue cell viability assays and scanning electron microscopy. Suture surface chemistry was analysed using X-ray photoelectron spectroscopy (XPS). Bulk RNA-Seq interrogated the transcriptional response of primary tendon-derived stromal cells to sutures after 14 days.
Results
The electrospun suture showed increased initial cell attachment compared to PDS II. XPS revealed that both sutures had similar local surface chemistry, indicating that the tendon-like architecture of electrospun suture was responsible for the greater cell attachment. Furthermore, electrospun suture elicited a stronger transcriptional response compared with PDS II, with relative enrichment of pathways including mTorc1 signalling and depletion of epithelial-to-mesenchymal transition and extracellular matrix gene sets. Neither suture induced transcriptional upregulation of inflammatory pathways.
Conclusion
Twisted electrospun sutures show promise in improving outcomes in surgical tendon repair by allowing increased cell attachment while maintaining a tissue response indicative of cell proliferation and wound healing, without significant fibrosis.
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Single cell multi-omics characterise discrete human tendon cells populations that persist in vitro and on fibrous scaffolds. Eur Cell Mater 2022; 44:1-20. [PMID: 35916474 DOI: 10.22203/ecm.v044a01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Chronic tendinopathy represents a growing healthcare burden in the ageing global population. Curative therapies remain elusive as the mechanisms that underlie chronic inflammation in tendon disease remain unclear. Identifying and isolating key pathogenic and reparative cells is essential in developing precision therapies and implantable materials for improved tendon healing. Multiple discrete human tendon cell populations have been previously described ex vivo. To determine if these populations persist in vitro, healthy human hamstring tenocytes were cultured for 8 d on either tissue culture plastic or aligned electrospun fibres of absorbable polydioxanone. Novel single-cell surface proteomics combined with unbiased single-cell transcriptomics (CITE-Seq) was used to identify discrete tenocyte populations. 6 cell populations were found, 4 of which shared key gene expression determinants with ex vivo human cell clusters: PTX3_PAPPA, POSTN_SCX, DCN_LUM and ITGA7_NES. Surface proteomics found that PTX3_PAPPA cells were CD10+CD26+CD54+. ITGA7_NES cells were CD146+ and POSTN_SCX cells were CD90+CD95+CD10+. Culture on the aligned electrospun fibres favoured 3 cell subtypes (DCN_LUM, POSTN_SCX and PTX3_ PAPPA), promoting high expression of tendon-matrix-associated genes and upregulating gene sets enriched for TNF-a and IL-6/STAT3 signalling. Discrete human tendon cell subpopulations persisted in in vitro culture and could be recognised by specific gene and surface-protein signatures. Aligned polydioxanone fibres promoted the survival of 3 clusters, including pro-inflammatory PTX3-expressing CD10+CD26+CD54+ cells found in chronic tendon disease. These results improved the understanding of preferred culture conditions for different tenocyte subpopulations and informed the development of in vitro models of tendon disease.
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134 A qualitative study of patient perceptions of immunoglobulin treatment regimens for inflammatory neuropathy. Journal of Neurology, Neurosurgery and Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
IntroductionWith RCT evidence of equivalency between intravenous (IVIg) and subcutaneous (SCIg) immunoglobulin in the management of CIDP, we sought to optimise uptake of homecare SCIg in our inflammatory neuropathy cohort. This is of particular importance in the context of the COVID pandemic.AimTo explore patient perception of IVIg and SCIg and understand treatment preferences.MethodsWe performed a non-hypothesis driven qualitative study of patient perception. Data was collected from adult patients with CIDP via an open-ended telephone interview and a focus group facilitated by medics independent members of the treating team. The data was coded using Braun and Clarke’s reflexive thematic analysis.Results11 patients were interviewed (mean age=51.55; S.D. 8.70, mean time on immunoglobulin treatment 61 months, S.D. 35.64). Patients found the treatment effective but highlighted perceived side-effects. The hospital environment (IVIg treatment) was reassuring but brought with it a range of difficulties, both logisti- cal and financial. Knowledge and direct experience of SCIg was lacking.ConclusionWe will develop a structured questionnaire based on these themes for broader application across the cohort. From this qualitative data we will continue to adapt our service in a patient focused manner and identify measures of quality improvement.emmacallanan1@nhs.net92
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ALK+ hyaline-vascular Castleman disease: A new kid on the block. Histopathology 2022; 80:1007-1010. [PMID: 35137445 DOI: 10.1111/his.14624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 11/29/2022]
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Abstract
Objective: The aim of the current study was to examine relations between sleep problems and family factors and early markers of ADHD in young children with and without a familial risk for ADHD.Methods: Differences in sleep behavior and family functioning in children under 6 years with (n = 72) and without (n = 139) a familial risk for ADHD were investigated. The influence of family and sleep factors on the development of early temperament markers of ADHD (effortful control and negative affect) was explored. Parents/caregivers completed questionnaires on family functioning, child sleep behavior, and general regulatory behaviors.Results: A significant difference was observed between high-risk and low-risk groups for family functioning in the infant/toddler (<3 years) and preschool (>3 years) cohorts. Parents of infants/toddlers in the high-risk group reported poorer infant sleep. However, there were no sleep differences reported for the preschool cohort. Family functioning was found to predict effortful control, while sleep quality predicted negative affect.Conclusion: The results of this study highlight potential family and sleep issues for young children with a familial history of ADHD and the potential influence of these factors on early temperament markers of ADHD. Future research should explore these relations further in order to better establish whether early sleep and family interventions could mitigate later ADHD symptomatology.
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FSHD. Neuromuscul Disord 2021. [DOI: 10.1016/j.nmd.2021.07.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The Effect of COVID-19 Related Stress on the Health and Wellness Behaviors of Faculty and Staff at a Mid-Size University. J Acad Nutr Diet 2021. [DOI: 10.1016/j.jand.2021.06.270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Implementation of a University Based Wellness Program in Response to Pandemic Related Loss of Community Nutrition Supervised Practice Rotations. J Acad Nutr Diet 2021. [DOI: 10.1016/j.jand.2021.06.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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The Barriers and Enablers to Participation in Wellness Behaviors Post COVID-19 among Faculty and Staff at a Mid-Size University. J Acad Nutr Diet 2021. [DOI: 10.1016/j.jand.2021.06.267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sensory wellbeing workshops for inpatient and day-care patients with anorexia nervosa. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT ÖSTERREICHISCHER NERVENÄRZTE UND PSYCHIATER 2021; 36:51-59. [PMID: 34129196 PMCID: PMC8204121 DOI: 10.1007/s40211-021-00392-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/23/2021] [Indexed: 12/03/2022]
Abstract
Background The wellbeing of patients with eating disorders is one of the priorities in the “bigger picture” of treatment for eating disorders. Sensory soothing strategies for sensory sensitivities are supportive tools which could be useful in day-care and inpatient clinical programmes. Methods Evaluation of multiple separate sensory wellbeing workshops consisting of psychoeducation and experiential components delivered in inpatient and intensive day-care services was performed. Participants’ self-report questionnaires were evaluated pre- and post-workshop. Additionally, patients’ comments and qualitative feedback was collected after completion of the workshop. Results There was strong evidence that self-reported awareness of sensory wellbeing, awareness of strategies to enhance sensory wellbeing, and confidence in managing sensory wellbeing increased after the workshops with positive qualitative feedback from participants. The feedback questionnaires highlighted that patients found the sessions useful and were able to use some of the skills and strategies they learned in the workshop. Conclusion This pilot work on sensory wellbeing workshops with a protocol-based format was feasible and beneficial for the patient group. Preliminary evidence suggests that delivery of similar workshops could be sensible in addition to treatment as usual in inpatient and day-care programmes.
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The female medical workforce. Anaesthesia 2021; 76:1142. [PMID: 33789357 DOI: 10.1111/anae.15471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 11/27/2022]
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ICU outcomes and survival in patients with severe COVID-19 in the largest health care system in central Florida. PLoS One 2021; 16:e0249038. [PMID: 33765049 PMCID: PMC7993561 DOI: 10.1371/journal.pone.0249038] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 03/09/2021] [Indexed: 12/16/2022] Open
Abstract
Background Observational studies have consistently described poor clinical outcomes and increased ICU mortality in patients with severe coronavirus disease 2019 (COVID-19) who require mechanical ventilation (MV). Our study describes the clinical characteristics and outcomes of patients with severe COVID-19 admitted to ICU in the largest health care system in the state of Florida, United States. Methods Retrospective cohort study of patients admitted to ICU due to severe COVID-19 in AdventHealth health system in Orlando, Florida from March 11th until May 18th, 2020. Patients were characterized based on demographics, baseline comorbidities, severity of illness, medical management including experimental therapies, laboratory markers and ventilator parameters. Major clinical outcomes analyzed at the end of the study period were: hospital and ICU length of stay, MV-related mortality and overall hospital mortality of ICU patients. Results Out of total of 1283 patients with COVID-19, 131 (10.2%) met criteria for ICU admission (median age: 61 years [interquartile range (IQR), 49.5–71.5]; 35.1% female). Common comorbidities were hypertension (84; 64.1%), and diabetes (54; 41.2%). Of the 131 ICU patients, 109 (83.2%) required MV and 9 (6.9%) received ECMO. Lower positive end expiratory pressure (PEEP) were observed in survivors [9.2 (7.7–10.4)] vs non-survivors [10 (9.1–12.9] p = 0.004]. Compared to non-survivors, survivors had a longer MV length of stay (LOS) [14 (IQR 8–22) vs 8.5 (IQR 5–10.8) p< 0.001], Hospital LOS [21 (IQR 13–31) vs 10 (7–1) p< 0.001] and ICU LOS [14 (IQR 7–24) vs 9.5 (IQR 6–11), p < 0.001]. The overall hospital mortality and MV-related mortality were 19.8% and 23.8% respectively. After exclusion of hospitalized patients, the hospital and MV-related mortality rates were 21.6% and 26.5% respectively. Conclusions Our study demonstrates an important improvement in mortality of patients with severe COVID-19 who required ICU admission and MV in comparison to previous observational reports and emphasizes the importance of standard of care measures in the management of COVID-19.
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Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study. INTERNATIONAL ORTHOPAEDICS 2021. [PMID: 32862265 DOI: 10.1007/s00264-020-04739-y/figures/2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
PURPOSE Thirty-day mortality of patients with hip fracture is well researched and predictive; validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality, and therefore, these patients are often exposed to COVID-19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients. METHODS A multicentre prospective study across ten sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019. RESULTS Actual and expected 30-day mortality was found to be significantly higher than expected for 2020 COVID-19 positive patients (RR 3.00 95% CI 1.57-5.75, p < 0.001), with 30 observed deaths compared against the 10 expected from NHFS risk stratification. CONCLUSION COVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the peri-operative period.
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1615. Isolation of Lytic Bacteriophages with Broad Host Range Activity Against Pseudomonas aeruginosa Strains Isolated from Respiratory Samples from Cystic Fibrosis Patients Intended for Therapeutic Application. Open Forum Infect Dis 2020. [PMCID: PMC7777938 DOI: 10.1093/ofid/ofaa439.1795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
With the rise of the antimicrobial resistance between different genera and species of bacteria, Phage Therapy is becoming a more realistic and accessible option for patients with limited or no antimicrobial options. Being able to have rapid access to a collection of clinical active phages is key for rapid implementation of phage therapy. The Microbiology Department at AdventHealth Orlando is performing routine screening of environmental and patient samples for isolation of phages against non-fermenting Gram negative bacteria to develop a Phage Bank.
Methods
Protocols for phage isolation from environmental sources such as lakes, rivers and sewers and clinical samples were developed. A series of respiratory, throat, stool and urine samples were processed following an internal protocol that includes centrifugation, filtration and enrichment. Clinical samples were centrifugated for 10 minutes, filtered using 0.45µm centrifugation filters, seeded with targeted host bacteria (clinical isolates) and incubated at 35°C for 24 hours. The enriched samples were centrifugated and filtered for a final phage enriched solution. Screening and isolation were performed using the Gracia method over trypticase soybean agar (TSA) for plaque morphology and quantification. Host range screening of other clinical isolates of P. aeruginosa was performed using the new isolated and purified phages.
Results
4 lytic phages against clinical strains of P. aeruginosa from patient with diagnosis of cystic fibrosis (CF), were isolated and purified from 4 different respiratory samples, including sputum and bronchial alveolar lavage. All phages showed phenotypical characteristics of lytic activity. 1 phage was active against 4 strains of P. aeruginosa, 1 phage was active against 2 strains of P. aeruginosa and the remaining 2 phages were active only against the initial host target strain.
Conclusion
With this study we demonstrated the potential use of clinical samples as source for isolating active bacteriophages against clinically significant bacteria strains. Clinical samples from vulnerable population of patients with chronic infections are part of our routine “phage-hunting” process to stock and grow our Phage Bank project for future clinical use.
Disclosures
All Authors: No reported disclosures
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1280. In-Vitro Activity of Cefiderocol, Imipenem/Relebactam, & Ceftazidime/Avibactam in Ceftolozane/Tazobactam Resistant Strains of Multidrug Resistant Pseudomonas aeruginosa. Open Forum Infect Dis 2020. [PMCID: PMC7776329 DOI: 10.1093/ofid/ofaa439.1463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background The activity of imipenem/relebactam (I/R), ceftazidime/avibactam (CZA) and cefiderocol (FDC) were evaluated against clinical isolates of multidrug resistant (MDR) strains of P. aeruginosa which was resistant to ceftolozane/tazobactam (C/T). The recent increase of MDR P. aeruginosa strains isolated from clinical samples has prompted research and development of new antimicrobials that can withstand its multiple resistance mechanisms. C/T is an effective option for treatment of MDR P. aeruginosa in our facility with only 10% of resistance in MDR strains, but the emergence of resistance may occur due to the presence of a carbapenemase gene or an ampC mutation. Methods Antimicrobial susceptibility testing for C/T Etest® (bioMérieux, Inc.) were performed on all MDR strains initially screened by the VITEK2® (bioMérieux, Inc.). 10% (n=20) of all MDR isolates were resistant to C/T by the CLSI 2019 breakpoints. These resistant isolates were tested for presence of a carbapenemase gene using the GeneXpert CARBA-R (Cepheid®) PCR and against CZA Etest® (bioMérieux, Inc.) I/R gradient strips (Liofilchem®) and FDC broth microdilution (Thermo Scientific™ Sensititre™). Results A total of 20 clinical isolates of MDR P. aeruginosa resistant to C/T were tested following standardized CLSI protocols and techniques. All 20 isolates were screened for the presence of a carbapenemase gene (blaVIM, blaNDM, blaKPC, blaOXA-48, blaIMP). A blaVIM gene was detected in 6 (30%) out of 20 isolates. FDC demonstrated the greatest activity with 85% (n=17) of susceptible isolates (CLSI MIC <4µg/dL). CZA (CLSI MIC <8µg/dL) and I/R (FDA MIC <2µg/dL) showed 15% (n=3) and 10% (n=2) of susceptible isolates respectively. FDC was active against all 6 blaVIM isolates, where all 6 strains were resistant to CZA and I/R as expected. 3 isolates tested non-susceptible against FDC; additional characterization was not performed at this time. Conclusion Based on these results, FDC demonstrated the greatest in-vitro activity against C/T resistant strains of MDR P. aeruginosa. FDC also demonstrated activity against all 6 MDR P. aeruginosa carrying blaVIM gene. FDC is a strong option to consider on MDR P. aeruginosa strains based on a resistance testing algorithm and a cost/effective protocol. Disclosures All Authors: No reported disclosures
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649. Clinical Implementation of a Rapid Susceptibility Testing Procedure, Directly From a Positive Blood Culture Using the Vitek®2 System on Gram Negative Rods. Open Forum Infect Dis 2020. [PMCID: PMC7777280 DOI: 10.1093/ofid/ofaa439.843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background The national average of identification and susceptibility for organisms isolated from positive blood culture to final susceptibility based on growth on solid media is 48 hours. The goal of this research was to prove that the Vitek®2 (bioMérieux, Inc.) system can provide an accurate and reliable susceptibility result directly from positive blood culture for Gram negative rods and reduce the turnaround time (TAT) from positive blood culture to the final susceptibility. Methods An FDA-modified validation procedure was performed on positive blood cultures directly from the bottle to the VITEK®2 System for susceptibility testing. The protocol tested and validated an aliquot of 50uL of blood directly from the positive bottle into 10 mL of saline (1:200). The solution was vortexed and 3mL were placed in the VITEK®2 test tube. This protocol was intended only for Gram negative rods using the AST-GN70, AST-GN81 & AST-GN801 cards. This protocol followed the CLSI M52 and M100 guidelines. Results 515 organisms from clinical blood culture samples from July 2018 to October 2019 were evaluated. Organisms included, but were not limited to: E. coli, K. pneumoniae, Enterobacter spp., and P. aeruginosa, Proteus spp., Salmonella spp., Acinetobacter spp., and S. maltophilia. There were 5,201 drug/bug combinations. AdventHealth Orlando achieved an essential agreement of 99.32% (n=5,166), minor error 0.74% (n=39) major error 0.02% (n=1) and very major error 0.49% (n=2). A 100% agreement was achieved on detection of ESBL, CRE, and MDR organisms. Conclusion Rapid direct blood culture protocol using the VITEK®2 System and the AST-GN cards is accurate, reliable and can be performed with less than 1 minute hands-on time. The protocol can be implemented in any laboratory at no additional costs or modification where the current VITEK®2 AST-GN panels are in use. This protocol was clinically implemented at AdventHealth Orlando on July 15, 2019. Compared with the national average of 72 hours, the TAT obtained during this study was 23 hours from positive blood culture to final susceptibility, a significant reduction of 25 hours. The authors encourage bioMérieux Inc. to evaluate and explore the opportunity to expand the use of the VITEK®2 system for this application with the appropriate clinical trial. Disclosures All Authors: No reported disclosures
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1607. Dual Therapy with Aztreonam & Ceftazidime/Avibactam Against Multi-Drug Resistant Stenotrophomonas maltophilia on Tricuspid Valve Endocarditis. Open Forum Infect Dis 2020. [PMCID: PMC7777778 DOI: 10.1093/ofid/ofaa439.1787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Antimicrobial resistance in Stenotrophomonas maltophilia is one of the most complex among Gram-negatives. Presence of regulating non-specific antimicrobial class efflux pumps and chromosomal encoded L1 metallo-betalactamase (Ambler Class B) and L2 betalactamase (Ambler Class A) are responsible for few clinically active antimicrobials and pan-drug resistant strains.
Methods
A 38 year old male with a history of IV drug use, chronic hepatitis C, and recent MSSA endocarditis was admitted with sepsis. Workup revealed tricuspid valve endocarditis with pulmonary septic emboli due to S. maltophilia. Initial antibiotics were levofloxacin (LVX), metronidazole, and piperacillin-tazobactam (TZP) followed by LVX and minocycline (MIN). He had valve replacement on day 6. Repeat blood cultures and valve tissue culture revealed pan-resistant S. maltophilia (resistant: ceftazidime (CAZ), LVX, MIN, TMP/SMX, chloramphenicol; intermediate: MIN; eravacycline MIC 8 μg/mL; tigecycline MIC 16 μg/mL). Microbiology Department was consulted for additional antimicrobial options. In vitro testing for aztreonam (ATM) with ceftazidime/avibactam (CZA) was recommended.
Results
Synergy testing between ATM and CZA was performed by positioning ATM strip over the area where CZA had been previously been placed and removed after 10 minutes of incubation. The interception of the growth with the ATM strip was read. In presence of avibactam, ATM MIC was 4 μg/mL, 6 two-fold dilutions lower than ATM without CZA. MIC for ATM (256 μg/mL), CAZ (256 μg/mL) and CZA (32 μg/mL) were tested individually. ATM with CZA was recommended as a salvage treatment based on in vitro result. Patient completed 6 weeks of ATM with CZA along with MIN. He achieved microbiologic clearance and clinical recovery from infection. At the end of treatment, he experienced episodes of refractory ascites. With complex comorbidities, patient was not a transplant candidate and transitioned to hospice two weeks later.
Conclusion
Although the surgical excision was key, treatment with ATM and CZA provided effective antimicrobial treatment in the setting of persistent positive blood culture. ATM with CZA should be considered for cases of pan-drug resistant S. maltophilia with limited treatment options.
Disclosures
All Authors: No reported disclosures
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1601. Combination Therapy versus Monotherapy for Carbapenem-resistant Organisms: Is More Really Better? Open Forum Infect Dis 2020. [PMCID: PMC7778249 DOI: 10.1093/ofid/ofaa439.1781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Carbapenem-resistant organisms (CROs) represent an urgent public health threat and associated with mortality rates up to 60%. Pharmacotherapy for these infections remain challenging and historically included multiple agents. Meropenem/vaborbactam and ceftazidime/avibactam are options to treat CRO infections as monotherapy; however, combination therapy is still frequently utilized. Data evaluating outcomes of patients who received combination therapy compared to those receiving monotherapy for CRO infections is limited.
Methods
This retrospective analysis was completed across 7 campuses at AdventHealth Orlando (AHO) from March 2018-October 2019. AHO implemented CRO PCR testing in March 2018, to identify carbapenemase producing CROs (CP-CROs). Inclusion criteria were hospitalization, age ≥ 18 years, culture with CP-CRO detected by PCR, and ≥ 72 hours of either monotherapy or combination therapy. Primary outcome was clinical success, defined as resolution of signs and symptoms of infection and absence of recurrent infection. Secondary outcomes included mean length of therapy, mean length of stay, inpatient mortality, adverse reactions and 30-day all cause readmissions.
Results
CRO was isolated 68 times in 59 unique patients (56% male, mean age 62 years). Most common sources included urine (41%), sputum (24%) and wound (22%). Commonly isolated organisms include K. pneumoniae (44%) and E. cloacae (29%). Thirty infections (44%) were polymicrobial and 28 patients (41%) had a secondary source of infection. Forty-three patients (63%) received definitive treatment therapy with a single antibiotic. Monotherapy treated patients had higher rates of treatment success (79% vs 68%, p=0.39), lower in-hospital mortality (4% vs 9%, p=0.066), less nephrotoxicity (6% vs 10%, p=0.084), shorter length of therapy (9.6 vs 13.4 days, p=0.034) and shorter hospital stay (20 vs 34 days, p=0.056). All-cause readmission rates were higher in the monotherapy group (18% vs 9%, p=0.78). Minimum inhibitory concentrations (MIC) were reported in 97% of patients.
Conclusion
Treatment with a single antibiotic for carbapenem-resistant infections can lead to treatment success, while minimizing adverse events, compared to utilizing combination therapy.
Disclosures
All Authors: No reported disclosures
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1270. Early Real-world Evidence in the Use of Eravacycline for the Management of Draconian Infections. Open Forum Infect Dis 2020. [PMCID: PMC7776886 DOI: 10.1093/ofid/ofaa439.1454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Eravacycline (ERV) is a next-generation tetracycline approved for complicated intra-abdominal infections (cIAI) with in-vitro activity to multidrug-resistant organisms such as carbapenem resistant Enterobacteriaceae, extended spectrum beta-lactamase, and carbapenem-resistant Acinetobacter baumannii (CRAB). The purpose of this study was to identify the utility of ERV in clinical practice.
Methods
Retrospective case series was conducted on patients at AdventHealth that received at least two doses of ERV. Primary endpoint for the study was clinical success while on ERV, meeting none of the following criteria: changing therapy, mortality, or lack of improvement from sign/symptoms.
Results
Of 23 patients, 74% were males with a mean age of 55 ±18 years and mean body weight of 79 ±27 kg. Mean APACHE II and Charleson scores were 20 (±11) and 6 (±4), respectively. 91% received ERV for an off-label indication or organism. Infection types were respiratory (44%), cIAI (35%), skin (9%), and other (13%). All patients had positive cultures, while 61% were treated as a polymicrobial infection and 17% had bacteremia. Microorganisms included A. xylosoxidans, S. maltophilia, CRAB, and K pneumoniae. 48% had ERV susceptibilities from .06-4 mcg/mL, including two MIC ≥32mcg/mL for S. maltophilia. 70% were given another antibiotic prior to ERV with a median duration of 5 (1-35) days. Median duration of ERV was 8 (3-30) days. 83% percent received ERV in combination with another antibiotic. During treatment, 26% had a Child-Pugh Class C at baseline and 30% had elevated liver function tests. No adverse drug reactions were reported. Upon discharge, 35% continued ERV. Clinical success was observed in 57% (12/21) of patients. Clinical outcome by infection type is summarized in Figure 1. Of 9 cases of clinical failure, 14% were changed to alternative, 19% died while on ERV, and 10% failed to resolve signs/symptoms. Two cases of M. abscessus infections had insufficient follow-up to assess clinical outcome.
Figure 1. Eravacycline Clinical Outcome by Infection Type
Conclusion
Initial real-world experience with ERV differs significantly from the trials regarding severity of illness, types of infection, and clinical outcomes. Further evaluation is necessary for using ERV as combination therapy and in off-label indications.
Disclosures
All Authors: No reported disclosures
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Abstract
Aims:To compare the effectiveness of a manualised group cognitive behaviour therapy (CBT) programme for people with bipolar disorder (BPD) and major depressive disorder (MDD).Method:In addition to treatment as usual (TAU), 17 people with BPD and 17 matched controls with MDD completed 8 or 12 sessions of twice weekly group CBT, followed by 6 booster sessions, held at monthly intervals. Participants completed the Structured Clinical Interview for DSM-IV Axis 1 Disorders, Clinician Version (SCID-1) and the University of Rhode Island Change Assessment (URICA) prior to therapy. They completed the Beck Depression Inventory - II (BDI), the Beck Anxiety Inventory (BAI), the Clinical Outcomes in Routine Evaluation (CORE), the World Health Organisation Quality of Life Brief Version (WHOQoL - BREF) and the Dysfunctional Attitudes Scale (DAS) before and after therapy and at the final follow-up session. The BDI and BAI were also completed at each group session.Results:Both groups showed statistically and clinically significant improvement on the BDI and BAI after treatment and at follow-up. Both groups showed a significant improvement on the psychological health sub-scale on the WHOQoL-BREF.Conclusions:Manualised group CBT leads to a reduction in the symptoms of depression and anxiety in people with both BPD and MDD and helps improve their perceived quality of life.Declaration of interest:None.
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The rate of bone loss slows after 1-2 years of initial antiretroviral therapy: final results of the Strategic Timing of Antiretroviral Therapy (START) bone mineral density substudy. HIV Med 2019; 21:64-70. [PMID: 31642586 DOI: 10.1111/hiv.12796] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Initial antiretroviral therapy (ART) causes loss of bone mineral density (BMD) over the first 1-2 years. Whether this loss continues with longer therapy is unclear. We determined changes in bone and spine BMD over 5 years in adults receiving immediate or deferred initial ART. METHODS In the Strategic Timing of Antiretroviral Therapy (START) BMD substudy, ART-naïve adults with CD4 counts > 500 cells/μL were randomized to immediate or deferred ART. Deferred group participants not yet on ART were offered ART after May 2015. Mean per cent changes in total hip and lumbar spine BMD (measured annually by dual-energy X-ray absorptiometry) were compared between groups using longitudinal mixed models. Fracture rates were also compared between groups for all START participants. RESULTS Substudy participants (immediate group, n = 201; deferred group, n = 210; median age 32 years; 80% non-white; 24% female) were followed for a mean 4.5 years until December 2016. In the immediate group, > 96% used ART throughout. In the deferred group, 16%, 58% and 94% used ART at years 1, 3 and 5, respectively. BMD decreased more in the immediate group initially; groups had converged by year 3 at the spine and year 4 at the hip by intent-to-treat (ITT). BMD changes after year 1 were similar in the immediate group and in those off ART in the deferred group [mean difference: spine, 0.03% per year; 95% confidence interval (CI) -0.4, 0.4; P = 0.88; hip, -0.2% per year; 95% CI -0.7, 0.3; P = 0.37]. Fracture incidence did not differ significantly between groups (immediate group, 0.86/100 person-years versus deferred group, 0.85/100 person-years; hazard ratio 1.01; 95% CI 0.76, 1.35; P = 0.98). CONCLUSIONS Significant ART-induced bone loss slowed after the first year of ART and became similar to that in untreated HIV infection.
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2275. Novel Therapeutic Options for the Treatment of Multi-Drug-Resistant Achromobacter Respiratory Infections. Open Forum Infect Dis 2019. [PMCID: PMC6809504 DOI: 10.1093/ofid/ofz360.1953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Respiratory infection due to Achromobacter species has been increasingly more common, especially in patients with cystic fibrosis (CF). Recurrent infections in these patients contribute to significant morbidity and mortality as well as lead to repeated antibiotic exposures with subsequent development of multi-drug-resistant (MDR) pathogens. Several recently approved antimicrobials target MDR Gram-negative pathogens, but none are FDA approved for MDR Achromobacter respiratory infections and lack susceptibility breakpoint recommendations. Methods This retrospective analysis evaluated hospitalized patients with MDR Achromobacter respiratory infections from August 2017 to March 2019 at AdventHealth Orlando, a 2,885-bed healthcare system including 8 campuses across Central Florida. The purpose of this descriptive study was to examine novel therapeutic agents for the treatment of respiratory infections due to MDR Achromobacter. Results MDR Achromobacter was isolated in 36 respiratory cultures from 18 unique patients. A. xylosoxidans (61%) and A. denitrificans (22%) were the most frequently isolated species. Mean patient age was 40 years, 56% were female, and 67% had CF. Treatment indications included CF exacerbation (38%), pneumonia (35%), post-lung transplant infection (16%), and other (11%). Twenty-four infections were polymicrobial (67%) and 23 infections included MDR pathogens. Minimum inhibitory concentrations (MIC) of the antibiotics used for treatment were available for 70% of cases. Of the 18 patients with isolated MDR Achromobacter organisms, 72% had MIC changes with 69% exhibiting higher MICs on subsequent testing. Novel agents were used in 63% of cases (Table 1) for an average duration of 10 days. Eravacycline was the most frequently used monotherapy agent (5/6 cases) and the most utilized novel antibiotic (21%). All-cause readmission rates at 30 days was 33%; 92% was due to infection. Inpatient all-cause mortality was 11%. Conclusion Antibiotics available to treat MDR Achromobacter infections are limited and lack standard susceptibility breakpoint recommendations. Based on this evaluation, novel agents, such as eravacycline or meropenem/vaborbactam, may be viable treatment options for patients with MDR Achromobacter respiratory infections. ![]()
Disclosures All authors: No reported disclosures.
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An Integrated Vaccine Clinic; a Novel Model of Care to Improve Vaccine Uptake in At-Risk Patient Groups. IRISH MEDICAL JOURNAL 2019; 112:1010. [PMID: 31651915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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EP.103Genetic and phenotypic characterisation of inherited myopathies in a tertiary neuromuscular centre. Neuromuscul Disord 2019. [DOI: 10.1016/j.nmd.2019.06.509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Impact of a national enhanced recovery after surgery programme on patient outcomes of primary total knee replacement: an interrupted time series analysis from "The National Joint Registry of England, Wales, Northern Ireland and the Isle of Man". Osteoarthritis Cartilage 2019; 27:1280-1293. [PMID: 31078777 DOI: 10.1016/j.joca.2019.05.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 04/02/2019] [Accepted: 05/01/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE We aimed to test whether a national Enhanced Recovery After Surgery (ERAS) Programme in total knee replacement (TKR) had an impact on patient outcomes. DESIGN Natural-experiment (April 2008-December 2016). Interrupted time-series regression assessed impact on trends before-during-after ERAS implementation. SETTING Primary operations from the UK National Joint Registry (NJR) were linked with Hospital Episode Statistics (HES) data which contains inpatient episodes undertaken in National Health Service (NHS) trusts in England, and Patient Reported Outcome Measures (PROMs). PARTICIPANTS Patients undergoing primary planned TKR aged ≥18 years. INTERVENTION ERAS implementation (April 2009-March 2011). OUTCOMES Regression coefficients of monthly means of Length of stay (LOS), bed day costs, change in Oxford knee scores (OKS) 6-months after surgery, complications (at 6 months), and rates of revision surgeries (at 5 years). RESULTS 486,579 primary TKRs were identified. Overall LOS and bed-day costs decreased from 5.8 days to 3.7 and from £7607 to £5276, from April 2008 to December 2016. Oxford knee score (OKS) change improved from 15.1 points in April 2008 to 17.1 points in December 2016. Complications decreased from 4.1 % in April 2008 to 1.7 % in March 2016. 5-year revision rates remained stable at 4.8 per 1000 implants years in April 2008 and December 2011. After ERAS, declining trends in LOS and bed costs slowed down; OKS improved, complications remained stable, and revisions slightly increased. CONCLUSIONS Different secular trends in outcomes for patients having TKR have been observed over the last decade. Although patient outcomes are better than a decade ago ERAS did not improve them at national level.
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Classification of rotator cuff tendinopathy using high definition ultrasound. Muscles Ligaments Tendons J 2019. [DOI: 10.32098/mltj.03.2014.20] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Randomized trial of three doses of vitamin D to reduce deficiency in pregnant Mongolian women. EBioMedicine 2018; 39:510-519. [PMID: 30552064 PMCID: PMC6354654 DOI: 10.1016/j.ebiom.2018.11.060] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/09/2018] [Accepted: 11/27/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In winter in Mongolia, 80% of adults have 25-hydroxyvitamin D (25(OH)D) concentrations <25 nmol/l (<10 ng/ml) and 99% have <50 nmol/l (<20 ng/ml). The vitamin D dose to avert deficiency during pregnancy in this population is unknown. METHODS We conducted a randomized, controlled, double-blind trial of daily 600, 2000, or 4000 IU vitamin D3 for pregnant women in Mongolia (Clinicaltrials.gov #NCT02395081). We examined 25(OH)D concentrations at baseline (12-16 weeks' gestation), 36-40 weeks' gestation and in umbilical cord blood, using enzyme linked fluorescent assay. Sample size was determined to detect 0.4 standard deviation differences in 25(OH)D concentrations with 80% power. FINDINGS 119 pregnant women were assigned 600 IU, 121 assigned 2000 IU and 120 assigned 4000 IU from February 2015 through December 2016. Eighty-eight percent of participants took ≥80% of assigned supplements. At baseline, 25(OH)D concentrations were similar across arms; overall mean ± standard deviation concentration was 19 ± 22 nmol/l; 91% were < 50 nmol/l. At 36-40 weeks, 25(OH)D concentrations increased to 46 ± 21, 70 ± 23, and 81 ± 29 nmol/l for women assigned 600, 2000, and 4000 IU, respectively (p < 0.0001 across arms; p = 0.002 for 2000 vs. 4000 IU). Mean umbilical cord 25(OH)D concentrations differed by study arm (p < 0.0001 across arms; p < 0.0001 for 2000 vs. 4000 IU) and were proportional to maternal concentrations. There were no adverse events, including hypercalcemia, attributable to vitamin D supplementation. INTERPRETATION Daily supplementation of 4000 IU during pregnancy is safe and achieved higher maternal and neonatal 25(OH)D concentrations than 2000 IU. Daily 600 IU supplements are insufficient to prevent vitamin D deficiency in Mongolia. FUND: Anonymous foundation and Brigham and Women's Hospital.
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1801. Impact of Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS) on Clinical Outcomes in Patients with Gram Positive Blood Cultures in a Diverse, Multicenter Healthcare System With a Central Laboratory. Open Forum Infect Dis 2018. [PMCID: PMC6254216 DOI: 10.1093/ofid/ofy210.1457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Rapid diagnostic testing in combination with real-time antimicrobial stewardship intervention can reduce time to de-escalation of empiric antibiotics and discontinuation of unnecessary therapy. This study aims to evaluate the clinical impact of Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS) for Gram-positive organism identification for blood cultures across a healthcare system comprised of pediatric, adult academic, and adult community hospitals utilizing a central microbiology laboratory with unique antimicrobial stewardship resources at each site. Methods This multicenter retrospective study compared patients with a positive blood culture for a Gram-positive organism identified via MALDI-TOF MS to a historical cohort identified using conventional methods. Primary outcome was time to optimal therapy (TTOT). Secondary outcomes included time to effective therapy, duration of therapy, time to microbiologic clearance, hospital length of stay (LOS), ICU LOS, recurrence, readmission, in-hospital mortality, and all-cause mortality. Results This study included 129 cultures (12% pediatric patients) in the conventional period and 129 cultures (19% pediatric patients) in the MALDI-TOF MS group. Of the total 258 blood cultures included, 147 (57%) represented true bloodstream infection and 111 (43%) were deemed to be contaminants. Despite a median reduction in time to organism identification (60.0 vs. 45.4 hours, P < 0.001), there was no difference in the primary outcome of overall median TTOT between the two groups (70.7 hours vs. 65.9 hours, P = 0.407). There were no significant differences for any secondary outcomes. Overall TTOT was longer as distance from the central laboratory increased (47.3 hours at central site vs. 76.9 hours at distance >30 miles). Among contaminants, median TTOT was reduced from 72.5 hours with conventional methods to 59.8 hours with MALDI-TOF MS (P = 0.015). Conclusion. Implementation of MALDI-TOF MS for organism identification may not reduce time to optimal therapy in patients with true Gram-positive bacteremia. However, it can result in a significant reduction in time to discontinuation of unnecessary therapy for patients with contaminated cultures. Figure 1. Differences in outcomes for conventional methods vs. MALDI-TOF MS ![]()
Disclosures All authors: No reported disclosures.
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Monitoring the effect of PI3K inhibition on HER2 therapy resistant breast cancer using serial analysis of PIK3CA mutant tumour DNA in plasma. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy269.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Non-invasive genotyping and monitoring of tumor evolution in locally advanced rectal cancer (LARC) patients using circulating tumor DNA (ctDNA). Ann Oncol 2018. [DOI: 10.1093/annonc/mdy281.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Artificial Intelligence to Predict Periprosthetic Joint Infection after Total Hip Replacement. Int J Surg 2018. [DOI: 10.1016/j.ijsu.2018.05.708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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An artificial neuronal network to predict revision surgery after total hip replacement. Int J Surg 2018. [DOI: 10.1016/j.ijsu.2018.05.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Comparison of clinical factors that impact disease activity in patients with inflammatory neuropathies. Neuromuscul Disord 2018. [DOI: 10.1016/s0960-8966(18)30352-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Evaluating predictors of invasive candidiasis in patients with and without candidemia on micafungin. Proc (Bayl Univ Med Cent) 2018; 31:30-34. [PMID: 29686548 DOI: 10.1080/08998280.2017.1396164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Numerous risk factors have been linked to invasive candidiasis; however, they are nonspecific and often trigger empiric antifungal therapy in a large number of patients. Identification of more precise predictors could promote judicious use of empiric echinocandins. In this retrospective review, 127 patients with blood cultures positive for Candida spp. were compared to a randomly selected cohort of 134 patients on empiric micafungin for ≥3 days and with blood cultures negative for Candida spp. Factors associated with candidemia included total parenteral nutrition (TPN; 26.0% vs 15.7%, P = 0.040), multifocal Candida colonization (23.6% vs 3.0%, P < 0.001), and positive 1,3-β-d-glucan assay (95.0% vs 35.0%, P < 0.001). Patients without candidemia on empiric micafungin were more likely to receive antibiotic therapy in the previous 10 days (55.9% vs 79.9%, P < 0.001) and to be taking immunosuppressive medications (11.0% vs 30.6%, P < 0.001). Receipt of TPN (odds ratio [OR] = 2.07, 95% confidence interval [CI], 1.02-4.21), severe sepsis (OR = 2.20, 95% CI, 1.00-4.83), and multifocal Candida colonization (OR = 13.87, 95% CI, 4.43-43.37) were independently associated with candidemia in the multivariable logistic regression model. Therefore, the absence of these risk factors, especially in conjunction with a negative 1,3-β-d-glucan assay, may be used to recommend de-escalation of empiric micafungin therapy.
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Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study. Clin Infect Dis 2017; 65:1316-1326. [PMID: 28531260 PMCID: PMC5850623 DOI: 10.1093/cid/cix480] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/19/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America. METHODS We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs). RESULTS We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions. CONCLUSIONS Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.
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Risk Factors for Candidemia as Compared with Patients with Negative Blood Cultures Placed on Empiric Micafungin. Open Forum Infect Dis 2017. [PMCID: PMC5631960 DOI: 10.1093/ofid/ofx163.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Numerous risk factors have been linked to invasive candidiasis; however, they are nonspecific and often trigger empiric antifungal therapy in a large number of patients. Identification of more precise predictors could promote judicious use of empiric echinocandins. Ultimately, this could decrease antifungal exposure, development of resistance, and associated costs. Methods This was a retrospective review of patients admitted to Baylor University Medical Center from 10/1/14 to 10/25/16. Patients with positive blood cultures for Candida spp. were compared with a randomly selected cohort of patients on empiric micafungin for 3 or more days and with blood cultures negative for Candida spp. This study excluded patients on prophylactic antifungals and patients with positive abscess cultures but negative blood cultures for Candida spp. Data was analyzed using the χ
2 test, t-test comparing means, and logistic regression as applicable. Results There were 127 patients with candidemia and 134 patients without candidemia on empiric micafungin. Factors associated with candidemia included positive 1,3-β-d-glucan assay (86.4% vs. 33.3%, P < 0.001), total parenteral nutrition (TPN) (26.0% vs. 15.7%, P = 0.040), and multifocal Candida colonization (35.3% vs. 4.5%, P < 0.001). Patients without candidemia on empiric micafungin were more likely to receive antibiotic therapy in the previous 10 days (55.9% vs. 79.9%, P < 0.001) and more likely to be taking immunosuppressive medications (11.0% vs. 30.6%, P < 0.001). There was no difference in mean length of stay (25.5 days vs. 27.3 days, P = 0.631) or 30-day all-cause mortality (32.3% vs. 23.9%, P = 0.131) between patients with candidemia and patients on empiric micafungin, respectively. Conclusion A negative 1,3-β-d-glucan assay in patients without multifocal Candida colonization or receiving TPN was inversely correlated with invasive candidiasis, as defined by candidemia. Therefore, the absence of these factors may be used to deescalate empiric micafungin therapy. Risk factors for candidemia identified in this study are consistent with previously published literature. These findings highlight an opportunity to improve empiric micafungin prescribing patterns at our institution. Disclosures All authors: No reported disclosures.
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Diagnostic and prognostic value of delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) in early osteoarthritis of the hip. Osteoarthritis Cartilage 2017; 25:1468-1477. [PMID: 28506842 DOI: 10.1016/j.joca.2017.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 04/15/2017] [Accepted: 05/04/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) can detect glycosaminoglycan loss in the acetabular cartilage of asymptomatic individuals with cam morphology. The aims of this study were to explore the relationship between cam morphology and dGEMRIC values, and to explore whether baseline dGEMRIC can predict the development of radiographic hip osteoarthritis. METHODS Prospective cohort (SibKids) study with clinical, radiographic, and MRI assessment at baseline and five-year follow-up (n = 34). The dGEMRIC values of cartilage regions were correlated with measures of cam morphology. Receiver operating characteristic (ROC) analysis was applied to baseline variables to predict radiographic loss of joint space width. RESULTS Superolateral acetabular cartilage dGEMRIC values were significantly lower in participants with cam morphology (P < 0.001), defined as an alpha angle greater than 60°. There was a negative correlation between alpha angle and the dGEMRIC value of adjacent acetabular cartilage. This relationship was strongest superoanteriorly (r = -0.697 P < 0.001). There was a positive correlation between baseline dGEMRIC and the magnitude of joint space width narrowing (r = 0.398 P = 0.030). ROC analysis of combined baseline variables (positive impingement test, alpha angle, dGEMRIC ratio) gave an Area Under the Curve (AUC) of 0.75 for predicting joint space width narrowing greater than 0.5 mm within 5 years. CONCLUSIONS The size and position of cam morphology determines the severity and location of progressive cartilage damage, supporting the biomechanical aetiology of femoroacetabular impingement. Baseline dGEMRIC is able to predict the development of radiographic osteoarthritis. Compositional MRI offers the potential to identify patients who may benefit from early intervention to prevent the development of osteoarthritis.
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Nucleoside reverse transcriptase inhibitor-reducing strategies in HIV treatment: assessing the evidence. HIV Med 2017; 19:18-32. [PMID: 28737291 DOI: 10.1111/hiv.12534] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 01/22/2023]
Abstract
Antiretroviral (ARV) therapy, comprising a backbone of two nucleos(t)ide reverse transcriptase inhibitors (NRTIs) plus another ARV, is the recognized standard of care (SOC), which has helped extend life expectancy in people living with HIV. In a quest to reduce lifelong drug exposure and minimize or avoid the toxicity of NRTIs, "NRTI-reducing" regimens have been investigated. This descriptive review assessing the results of NRTI-reducing strategies from the largest randomized trials focuses on virological efficacy, resistance, regimen safety (in terms of bone mineral density, renal function, lipids and central nervous system function) and simplicity. The review considers efficacy across various NRTI-sparing strategies, for example an integrase strand transfer inhibitor (INSTI) plus a ritonavir-boosted protease inhibitor (PI/r) or PI/r + lamivudine (3TC), in both naïve and switch regimes. Of 10 key studies in treatment-naïve adults assessing five NRTI-reducing strategies, only four studies demonstrated noninferiority vs. SOC [GARDEL, NEAT 001, AIDS Clinical Trials Group 5142 and PROGRESS]. In switch settings, 17 studies (10 randomized) were reviewed that used four strategies, including three studies assessing an INSTI plus a nonnucleoside reverse transcriptase inhibitor . Noninferiority of the NRTI-reducing arm was shown in six of 10 studies (ATLAS-M, SALT, DUAL, OLE, LATTE-2 and SWORD). In general, NRTI-reducing therapy did not always result in an improvement in short- or long-term adverse events; however, in many cases, these endpoints were not reported. Some of these studies reported higher virological failure rates with more frequent emergence of resistance mutations. None of these NRTI-reducing strategies has been compared against a single-pill regimen, including those containing tenofovir alafenamide. Only strategies demonstrating noninferior efficacy, a benefit in safety/tolerability, and a favourable cost-efficacy ratio, preferably in a single pill, will eventually match the current SOC of triple ARV therapy.
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THE ROLE OF REGULATION IN POLICY FOR AUSTRALIAN DEMENTIA CARE. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.3587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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CAN MATURE-AGE NONTRADITIONAL STUDENTS SUCCEED IN AN ONLINE BACHELOR OF DEMENTIA CARE PROGRAM? Innov Aging 2017. [DOI: 10.1093/geroni/igx004.1399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Resorbable electrospun polydioxanone fibres modify the behaviour of cells from both healthy and diseased human tendons. Eur Cell Mater 2017; 33:169-182. [PMID: 28266691 DOI: 10.22203/ecm.v033a13] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Chronic tendinopathy in an active and ageing population represents an increasing burden to healthcare systems. Rotator cuff tendinopathy alone accounts for approximately 70 % of all shoulder pain. Tendinopathic tissue has a disorganised extracellular matrix, altered vasculature, and infiltration of fibroblasts and inflammatory cells. This altered biology may contribute to the limited success of surgical repair strategies. Electrospun resorbable scaffolds can potentially enhance endogenous repair mechanisms by influencing the tissue microenvironment. Polydioxanone (PDO) has an established safety profile in patients. We compared the response of healthy and diseased human tendon cells to electrospun PDO fibres using live cell imaging, proliferation, flow cytometry, and gene expression studies. Within 4 h of initial contact with electrospun PDO, healthy tendon cells underwent a marked transformation; elongating along the fibres in a fibre density dependent manner. Diseased tendon cells initially responded at a slower rate, but ultimately underwent a similar morphological change. Electrospun fibres increased the proliferation rate of diseased tendon cells and increased the ratio of type I:IIIcollagenmRNA expression. Flow cytometry revealed decreased expression of CD106, a marker of mesenchymal stem cells, and increased expression of CD10 on healthy versus diseased tendon cells. PDO electrospun scaffolds further promoted CD106negCD10pos expression of healthy tendon cells. Despite their behavioural differences, both healthy and diseased human tendon cells responded to electrospun PDO fibres. This encourages further work establishing their efficacy in augmenting surgical repair of diseased tendons.
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Effectiveness of open and arthroscopic rotator cuff repair (UKUFF): a randomised controlled trial. Bone Joint J 2017; 99-B:107-115. [PMID: 28053265 DOI: 10.1302/0301-620x.99b1.bjj-2016-0424.r1] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 09/23/2016] [Indexed: 11/05/2022]
Abstract
AIMS The appropriate management for patients with a degenerative tear of the rotator cuff remains controversial, but operative treatment, particularly arthroscopic surgery, is increasingly being used. Our aim in this paper was to compare the effectiveness of arthroscopic with open repair of the rotator cuff. PATIENTS AND METHODS A total of 273 patients were recruited to a randomised comparison trial (136 to arthroscopic surgery and 137 to open surgery) from 19 teaching and general hospitals in the United Kingdom. The surgeons used their usual preferred method of repair. The Oxford Shoulder Score (OSS), two years post-operatively, was the primary outcome measure. Imaging of the shoulder was performed at one year after surgery. The trial is registered with Current Controlled Trials, ISRCTN97804283. RESULTS The mean OSS improved from 26.3 (standard deviation (sd) 8.2) at baseline, to 41.7 (sd 7.9) two years post-operatively for arthroscopic surgery and from 25.0 (sd 8.0) to 41.5 (sd 7.9) for open surgery. Intention-to-treat (ITT) analysis showed no statistical difference between the groups at two years (difference in OSS score -0.76; 95% confidence interval (CI) -2.75 to 1.22; p = 0.452). The confidence interval excluded the pre-determined clinically important difference in the OSS of three points. The rate of re-tear was not significantly different between the two groups (46.4% for arthroscopic and 38.6% for open surgery; 95% CI -6.9 to 25.8; p = 0.256). Healed repairs had the most improved OSS. These findings were the same when analysed per-protocol. CONCLUSION There is no evidence of difference in effectiveness between open and arthroscopic repair of rotator cuff tears. The rate of re-tear is high in both groups, for all sizes of tear and ages and this adversely affects the outcome. Cite this article: Bone Joint J 2017;99-B:107-15.
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Lower coronary plaque burden in patients with HIV presenting with acute coronary syndrome. Open Heart 2016; 3:e000511. [PMID: 28123757 PMCID: PMC5237750 DOI: 10.1136/openhrt-2016-000511] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/20/2016] [Accepted: 11/17/2016] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Treated HIV infection is associated with a higher incidence of coronary artery disease and myocardial infarction, although the mechanisms remain unclear. We sought to characterise the burden of coronary artery disease in men with HIV using retrospective data from invasive coronary angiograms in patients presenting with acute coronary syndrome (ACS). METHODS Demographic and coronary angiographic data were obtained from 160 men with ST elevation myocardial infarction, non-STEMI or high-risk chest pain; 73 HIV-infected cases and 87 age-matched controls. The burden of coronary disease was calculated using the Gensini Angiographic Scoring System by 2 independent cardiologists blinded to HIV status. RESULTS The 2 groups were matched for age, sex and cardiac event subtype and there was no difference in rates of smoking or cholesterol levels. Compared with control participants, patients with HIV had higher usage of antihypertensives (46 (63%) vs 30 (35%), p<0.001) and statins (47 (64%) vs 29 (33%), p<0.001). There was no difference in plaque distribution between both groups; however, the Gensini score was 42% lower in cases with HIV than in controls (p<0.03). C reactive protein was higher in cases with HIV (13.4±15.4 vs 3.7±3.6). CONCLUSIONS Men with HIV presenting with ACS paradoxically had a lower burden of coronary plaque than matched controls, despite more aggressive risk factor management, suggesting that plaque vulnerability, rather than total burden of atherosclerosis, may be important in the pathophysiology of coronary artery disease in men with HIV.
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A longitudinal cohort study of HIV 'treatment as prevention' in gay, bisexual and other men who have sex with men: the Treatment with Antiretrovirals and their Impact on Positive And Negative men (TAIPAN) study protocol. BMC Infect Dis 2016; 16:752. [PMID: 27955627 PMCID: PMC5154018 DOI: 10.1186/s12879-016-2073-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 11/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Australia has increased coverage of antiretroviral treatment (ART) over the past decade, reaching 73% uptake in 2014. While ART reduces AIDS-related deaths, accumulating evidence suggests that it could also bolster prevention efforts by reducing the risk of HIV transmission ('treatment as prevention'). While promising, evidence of community-level impact of treatment as prevention on reducing HIV incidence among gay and bisexual men is limited. We describe a study protocol that aims to determine if scale up of testing and treatment for HIV leads to a reduction in community viraemia and, in turn, if this reduction is temporally associated with a reduction in HIV incidence among gay and bisexual men in Australia's two most populous states. METHODS Over the period 2009 to 2017, we will establish two cohorts making use of clinical and laboratory data electronically extracted retrospectively and prospectively from 73 health services and laboratories in the states of New South Wales and Victoria. The 'positive cohort' will consist of approximately 13,000 gay and bisexual men (>90% of all people living with HIV). The 'negative cohort' will consist of at least 40,000 HIV-negative gay and bisexual men (approximately half of the total population). Within the negative cohort we will use standard repeat-testing methods to calculate annual HIV incidence. Community prevalence of viraemia will be defined as the proportion of men with a viral load ≥200RNA copies/mm3, which will combine viral load data from the positive cohort and viraemia estimates among those with an undiagnosed HIV infection. Using regression analyses and adjusting for behavioural and demographic factors associated with infection, we will assess the temporal association between the community prevalence of viraemia and the incidence of HIV infection. Further analyses will make use of these cohorts to assess incidence and predictors of treatment initiation, repeat HIV testing, and viral suppression. DISCUSSION This study will provide important information on whether 'treatment as prevention' is associated with a reduction in HIV incidence at a community level among gay and bisexual men.
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The effect of dalteparin on thromboelastography in pregnancy: an in vitro study. Int J Obstet Anesth 2016; 28:22-27. [DOI: 10.1016/j.ijoa.2016.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 08/03/2016] [Accepted: 08/23/2016] [Indexed: 11/27/2022]
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Costs, quality of life and cost-effectiveness of arthroscopic and open repair for rotator cuff tears: an economic evaluation alongside the UKUFF trial. Bone Joint J 2016; 98-B:1648-1655. [PMID: 27909127 DOI: 10.1302/0301-620x.98b12.bjj-2016-0121.r1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/03/2016] [Indexed: 11/05/2022]
Abstract
AIMS A trial-based comparison of the use of resources, costs and quality of life outcomes of arthroscopic and open surgical management for rotator cuff tears in the United Kingdom NHS was performed using data from the United Kingdom Rotator Cuff Study (UKUFF) randomised controlled trial. PATIENTS AND METHODS Using data from 273 patients, healthcare-related use of resources, costs and quality-adjusted life years (QALYs) were estimated at 12 months and 24 months after surgery on an intention-to-treat basis with adjustment for covariates. Uncertainty about the incremental cost-effectiveness ratio for arthroscopic versus open management at 24 months of follow-up was incorporated using bootstrapping. Multiple imputation methods were used to deal with missing data. RESULTS There were no significant differences between the arthroscopic and open groups in terms of total mean use and cost of resources or QALYs at any time post-operatively. Open management dominated arthroscopic management in 59.8% of bootstrapped cost and effect differences. The probability that arthroscopic management was cost-effective compared with open management at a willingness-to-pay threshold of £20 000 per QALY gained was 20.9%. CONCLUSION There was no significant overall difference in the use or cost of resources or quality of life between arthroscopic and open management in the trial. There was uncertainty about which strategy was most cost-effective. Cite this article: Bone Joint J 2016;98-B:1648-55.
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Extracorporeal shockwave therapy and therapeutic exercise for supraspinatus and biceps tendinopathies in 29 dogs. Vet Rec 2016; 179:385. [DOI: 10.1136/vr.103487] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2016] [Indexed: 12/20/2022]
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